MHA/OHA HIIN Antibiotic Stewardship/MDRO Collaborative · MHA/OHA HIIN Antibiotic Stewardship/MDRO...
Transcript of MHA/OHA HIIN Antibiotic Stewardship/MDRO Collaborative · MHA/OHA HIIN Antibiotic Stewardship/MDRO...
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Place picture here
May 9, 2017
MHA/OHA HIIN Antibiotic Stewardship/MDRO Collaborative
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Please note – this webinar is being recorded.
▪ For best sound quality, dial in at 1-800-791-2345 and enter code 11076
▪ Mute your phone during the presentation
▪ Don’t put the call on hold
▪ Please use the chat box to ask questions!
Reminders
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Housekeeping
▪ Education Credit
• Nursing Education Credit – 1 hour
• Pharmacy Education Credit – 0.1
o Pharmacists, please list your license number on the sign-in sheet to receive credit
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Agenda
▪ Welcome
▪ Presentation:
• Environmental Interventions to Reduce Clostridium difficile by Jessica Nerby, MPH, CIC, CLS
▪ Questions/discussion
▪ Wrap-up
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Environmental Interventions to
Reduce Clostridium difficileAngus Hayes (Environmental Services)
Carol Nassif (Infection Prevention)
Jessica Nerby (Infection Prevention)
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Objectives
• Identify recommendations for preventing
Clostridium difficile (C. difficile) infections
• Describe the importance of the environment in
controlling C. difficile infections
• List the SHEA environmental control
recommendations for C. difficile
• Summarize the Abbott Northwestern Hospital
environmental interventions and important
learnings
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C. difficile Background
• 453,000 cases annually
• 29,000 deaths
• Attributable costs $6.3 billion
• Clinical manifestation range from self-limiting
diarrhea to toxic megacolon and sepsis
• Hospital stays for C. difficile have increased 3-
fold over the last decade
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C. difficile Infection Prevention
• Appropriate antibiotic use
• Contact precautions for infected patients
• Educate staff, providers, patients and their
families
• Measure compliance with hand hygiene
• Ensure cleaning and disinfection of equipment
and the environment
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The Environment and C. difficile
• Patients admitted to a C. difficile room are at
higher risk of getting C. difficile1,2
• Improving environmental cleaning decreases the
rate of C. difficile room contamination3 and rates
of hospital acquired C. difficile4,5
9
1. Mitchell BG. J Hosp Infection 20152. Shaughnessy. Infect Control Hosp Epidemiol. 20113. Sitzlar. Infect Control Hosp Epidemiol. 20134. Orenstein Infect Control Hosp Epidemiol. 20115. Mayfield. Clin Infect Dis 2000
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SHEA Recommendations -
Cleaning• Ensure cleaning and disinfection of equipment and the
environment
• Consider using 1:10 dilution of bleach or other product with EPA approved claim for C. difficile sporicidal activity in outbreak and hyperendemic setting
• Develop and implement protocols for disinfection of equipment and the environment- Assess adherence to protocols on routine basis
- Assess adequacy of cleaning before switching to new product
- Educate EVS personnel on cleaning and disinfection technique
• Clean shared equipment between patients and ensure all room dedicated equipment is cleaned on patient discharge
10Dubberke. Infect Control Hosp Epidemiol. 2014
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Abbott Northwestern
Background
• 630 bed hospital in
Minneapolis, MN
• 62 ICU beds
• 6,000 staff, serving
200,000 patients
annually
• Magnet Recognition
Program Status since
2009
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ANW C. difficile Reduction
• Multidisciplinary C. difficile taskforce formed in 2010- Infection Prevention
- Nursing leadership and bedside nursing
- Physicians (hospitalists and ID)
- Performance Improvement/Quality
- Environmental services
- Pharmacy
• Subgroups- Education
- Cleaning
- Antibiotic Stewardship
• Reports to Infection Prevention and Control Committee
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Environmental Services Work
• 2010- Allina group of IP and EVS meet to develop standardized
cleaning protocols
- Assessment of all items in a patient room/on unit
- Implement the use of 2 color microfiber cleaning cloths
- Standardize bleach cleaning for C. difficile rooms
- Standardized UV gel testing procedure
• 2011- Day-long EVS staff training with return demo room
cleaning
- Unit cleaning responsibilities outlined
- Development of one page high touch surface cleaning cards
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Item Accountability Audit
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Results from Initial EVS Work
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Example Reports
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Unit Cleaning Checklist
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Additional Interventions
• Additional hand hygiene sinks added 2012
• UV light treatment added 6/2012 (2nd machine
added 1/13)
• Provider and staff education
• Infectious Disease pharmacist conducting
antibiotic stewardship audits
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C. difficile rates
20
0.00
5.00
10.00
15.00
20.00
25.00
20101
20102
20103
20104
20105
20106
20107
20108
20109
201010
201011
201012
20111
20112
20113
20114
20115
20116
20117
20118
20119
201110
201111
201112
ANW Lab ID Rate/10,000 pt-days
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Adjunct Room Cleaning
Technologies
• Rationale for using
- Hospital rooms may not be thoroughly cleaned between
discharges leading to increase risk of infection for the next
patient
- 13 studies published demonstrating no-touch technology
decreases incidence and/or prevalence of MDROs
• Types
- UV
- Hydrogen peroxide
• Aerosolized HP
• H2O2 vapor systems
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References1. Weber. Am J Infect Control 20162. Weber. Curr Opinion Infec Dis 20163. Anderson. Lancet 20174. Passaretti. Clin Infect Dis 20135. Pegues. Infect Control Hosp Epidemiol 2017
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UV Systems
• Mechanism of action – UV breaks molecular bonds in DNA
• Efficacy dependent on- Organic load
- Type of pathogen
- Light intensity and dose
- Exposure time
- Direct line of sight or shaded
- Room size/shape and type of surfaces
• Study results- >3 log10 reduction in vegetative organisms (varied exposure times dependent on
device type: 5-25 minutes)
- Requires more time and energy to kill spores/spore forming organisms
- Level of inactivation in direct line of sight may be up to 2 log10 more compared to C. difficile not in direct line of sight
• Advantages – shorter treatment time
• Disadvantages – only inactive in direct or indirect line of sight. Log reduction less than that of HP
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HP Systems
• Mechanism of action – high reactive hydroxyl radicals attach DNA, membranes, lipids
• Effectiveness well studied >6 log10 reduction of sporicidal organisms; >4 log10 reduction of MRSA, VRE, MDR-Ab
• Advantages – demonstrated activity including against spore forming bacteria
• Disadvantages: Usually required HVAC system to be sealed, longer treatment time vs UV (1.5-8 hours)
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Considerations Prior to Use
• Not a substitute for good room cleaning
practices (still need mechanical removal of soil)
• Choose systems that have demonstrated ability
to decrease HAIs
• Weigh advantages/disadvantages of systems
• Determine if additional FTE resources are
needed to operationalize use and include in your
request for purchase
24
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Best Laid Plans
• Change in EVS management 10/2011
• Varied practice between IP and EVS managers
for UV audit collection
- Size and placement of marks
- Interpretation/grading
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EVS vs IP Audit Results
IP Audits EVS Audits
Overall Room Pass Rates 62% 93%
Bedside Table 88% 97%
Bed Rails 63% 91%
Toilet Flush 89% 97%
Toilet Seat 85% 93%
Bathroom Light Switch
Bathroom Door Handle
75%
74%
88%
93%
Patient Room Light Switch
Patient Room Door Handle
68%
70%
90%
90%
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EVS Interventions
• Multiple training
for EVS leaders
around how to
conduct UV gel
testing
• Asking for follow-
up with EVS staff
person that
cleans non-
passing room
27
IP Audits EVS Audits
Overall Room Pass Rates 81% 96%
Bedside Table 94% 98%
Bed Rails 68% 92%
Toilet Flush 90% 97%
Toilet Seat 93% 99%
Bathroom Light Switch
Bathroom Door Handle
79%
90%
91%
94%
Patient Room Light Switch
Patient Room Door Handle
89%
84%
92%
94%
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Environmental Cleaning 2.0
• New EVS leadership (1/2015)
• New product (universal sporicidal use 9/15)
• Re-training (3Q 15)
• Emphasis on employee accountability (4Q15)
• EVS manager auditing (4Q15)
• EVS manager training (1Q16)
• Creating of daily and terminal cleaning videos
• New patient privacy curtains and exchange schedule
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Cleaning Compliance Results
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% Rooms Passing
1Q15 2Q15 3Q15 4Q15 1Q16 2Q16 3Q16 4Q16 1Q17
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Additional Interventions
• Additional FTE for antibiotic stewardship (2015)
• New antibiotic stewardship team (2016)
- Additional MD members
- Reporting through P/T
• Unit huddles around C. difficile testing (2016)
• Emphasis rejection of non-liquid stools (4Q15)
• IP protocol to cancel uncollected tests at 48
hours
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C. Difficile rates
31
0.00
2.00
4.00
6.00
8.00
10.00
12.00
20151
20152
20153
20154
20155
20156
20157
20158
20159
201510
201511
201512
20161
20162
20163
20164
20165
20166
20167
20168
20169
201610
201611
201612
20171
20172
20173
ANW Lab ID Rate/10,000 pt-days
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Summary of Key Environmental
Cleaning Interventions
• Standardization of cleaning process with training
and test of knowledge
• Implementation of cleaning monitoring (EVS and
unit cleaning)
• UV room disinfection as adjunct to standard
cleaning processes
• Implementation of universal sporicidal
disinfectant
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Environmental Cleaning Key
Learnings
• Assign accountability for cleaning items
• Consistent training in how to conduct audits
between IP and EVS leaders
• Staff training and expectations
• Holding staff accountable for results
• Getting EVS the right equipment to do the job
• Share results and celebrate successes
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C. difficile Reduction Key
Learnings
• Multiple interventions needed to impact rates
• Multidisciplinary taskforce allowed for cross
reporting and planning
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Minnesota Hospital Association
resources
• Example education slides for EVS staff
• Example EVS cleaning guidebook
• UV gel “how to” presentation and testing
procedures
• Example UV gel audit tool
• EVS room cleaning training certificate
http://www.mnhospitals.org/controllingcdi#/videos/li
st
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Questions
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ASP 101
▪ New offering from MHA/OHA HIIN!
▪ Intended for small hospitals working to meet CDC Core Elements for an ASP
▪ June – December 2017
▪ Stay tuned for registration details
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MHA/OHA HIIN Contacts
▪ OHA• James Guliano, Vice President Quality Programs• Rosalie Weakland, Senior Director Quality Programs• Subcontractor – HSAG
o Christine Bailey, Director, Quality Improvement and Patient Safety
▪ MHA• Tania Daniels, Vice President, Quality and Patient
Safety• Lali Silva, Senior Director Quality and Process
Improvement• Susan Klammer, Quality/Safety Project Coordinator
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Thank you for joining us!
Next Webinar:
Wednesday, June 14 at 8:00am CST/ 9am EST[Webinar details will be sent at a later date]